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R  D529  C85  Wounds  of  the  brain 


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CEAYiPORD 


^OUHDS   OF  TEE  BRA.IN. 


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Wounds  of  the  Brain 


DR.  JOHN  B.  CRAWFORD 


COLUMBIA  UNIVERSITY 

DEPARTIViENT  OF  PHYSIOLOGY 

College  of  Physicians  and  Surgeons.' 
487  west  fifty  ninth  street 

NEW  YORK 


lO 


WOUiNDS  OF  THE  BRAIN 

AN    ESSAY 


READ  BY  APPOINTMENT  BEFORE  THE 

LUZERNE   COUNTY    MEDICAL   SOCIETY 

AT  WILKES-BARRE,  JAN'Y  14,  1885 
BY 

Dr.  J.  B.  CRAWFORD 


PUBLISHED  BY  REQUEST  OF  THE  SOCIETY 


wilkes-barre,  pa.  : 

Prkss  ok  The  Wilkes-Barre  Record 

m.  dccc.  lxxxv. 


%^^-OlAA^ 


WOUNDS  OF  THE  BRAIN. 


There  are  two  classes  of  diseases,  and  likewise  of 
injuries,  the  treatment  of  which  has  not  yet  been  very  gen- 
erally agreed  upon,  and  which  seems  likely  to  long  remain 
unsettled.  I  refer  to  those  widely  differing  conditions  in 
which  the  disease  or  the  injury  is  so  slight  that  the  unaided 
efforts  of  nature  usually  suffice  to  effect  a  restoration  to 
health,  or  a  complete  repair  of  the  injury;  and  to  those 
malignant  diseases  and  grave  injuries  irt  which  the  best 
directed  therapeutic  or  surgical  skill  appears  to  exert  but 
little  power  in  averting  a  fatal  termination.  Whatever  is 
done  for  the  one  class  of  cases  seems  to  succeed;  and  con- 
sequently an  endless  variety  of  supposed  remedies  and  of 
surgical  procedures,  each  asserting  superiority  over  its 
rivals,  claims  our  adoption;  while,  on  the  other  hand,  what- 
ever means  we  apply  or  whatever  measures  we  adopt,  are 
usually  doomed  to  failure,  and  acquire  only  disrepute. 

The  subject  of  our  discussion  to-day — wounds  of  the 
brain — is  mainly  included  in  the  latter  class.  They  are 
always  of  grave  import;  yet  while  none  are  so  trivial  as  to 
be  destitute  of  danger,  or  to  be  disregarded  in  treatment, 
few,  which  are  not  immediately  fatal,  are  so  severe  as  to 
preclude  the  possibility  of  recovery.  It  becomes  impor- 
tant, therefore,  for  the  surgeon  to  determine  how  to  direct 
his  efforts,  in  treating  this  class  of  injuries,  so  as  to  secure 
the  largest  measure  of  that  limited  success  that  is  attainable. 

That  great  central  mass  of  nervous  matter  called  the 
brain  or  encephalon,  is  confined  within  the  bony  cavity  of 


the  cranium,  which  it  closely  fills.  It  is  surrounded  by  a 
strong  fibrous  envelope  which  closely  invests  its  exterior 
and  applies  itself  to  all  the  intricacies  of  its  conformation. 
It  consists,  in  the  main,  of  a  central  mass  of  white  medul- 
lary matter  surrounded  by  an  envelope  of  gray  or  cortical 
substance.  Originating  in  the  peripheral  or  gray  matter, 
innumerable  nerve- fibres  connect  the  corresponding  por- 
tions of  the  hemispheres,  associate  the  different  organs, 
and  converge  from  every  portion  of  the  periphery  of  the 
cerebrum  to  penetrate  the  ganglia  at  its  base,  and  pass  into 
its  closely  associated  organ,  the  spinal  cord.  The  blood 
supply  of  this  organ  is  derived  from  the  internal  carotid 
and  vertebral  arteries.  These  several  vessels,  uniting,  form 
an  important  vascular  plexus  at  the  cerebral  base,  and  send 
their  diminishing  branches  towards  its  periphery.  It  will 
thus  be  seen  that  the  more  highly  vitalized  parts  of  this 
organ  are  located  in  its  central  basilar  portions ;  that  the 
nerve-fibres,  upon  the  integrity  of  which  the  continued 
vitality  and  functional  activity  of  all  other  portions  of  the 
system  depends,  are  concentrated  in  this  portion  of  the 
brain;  and  that  the  vascular  supply  of  the  entire  organ  is 
concentrated  in  the  same  locality.  If  we  trace  either  the 
nerve  fibres  or  the  arteries  from  this  central  portion,  we 
find  them  diminishing  in  size  and  in  relative  proportion  to 
their  surrounding  tissues,  as  they  approach  the  external 
portions  of  the  hemispheres.  These  anatomical  characters 
of  the  brain  may  help  us  to  understand  why  it  is  that  so 
widely  different  results  follow  apparently  similar  injuries  of 
the  brain;  and  why  it  is  that  recovery  will  at  one  time 
follow  extensive  destruction  of  the  cerebral  mass,  while  the 
slightest  injury  of  another  portion  is  instantaneously  fatal. 
It  may  be  well,  too,  for  purposes  of  diagnosis,  to  note 
some  physiological  facts  in  relation  to  this  organ.  The 
hemispheres  are  so  slightly  associated  with  the  functions 
of  physical  life,  that  extensive  destruction  or  removal  of  a 


5 

considerable  portion  of  their  substance  may  take  .place 
without  necessitating  a  fatal  result.  They  seem  to  be 
especially  connected  with  the  manifestation  of  conscious 
intelligence;  and  while  their  complete  integrity  is  essential 
to  the  highest  manifestation  of  intellectual  power,  extensive 
portions  of  their  substance  may  suffer  morbid  alteration, 
mechanical  injury,  or  destruction  of  substance  without 
necessitating  a  fatal  result,  or  an  entire  abolition  of  mental 
power.  They  combine  the  mechanism  of  conscious  sensa- 
tions and  voluntary  movements.  The  recent  improvements 
in  our  knowledge  of  cerebral  physiology  relate  chiefly  to 
the  localization  of  these  powers.  They  demonstrate  that 
certain  portions  of  the  cerebral  cortex  are  connected  with 
the  phenomena  of  motion,  others  with  sensation,  while 
still  others  are  associated  with  nervous  phenomena  of  diffe- 
rent kinds.  "The  cerebral  hemispheres,"  says  Dalton,  "do 
not  act  indiscriminately,  as  a  whole;  but  the  convolutions 
of  particular  regions  have  a  structure  and  properties  differ- 
ing from  those  elsewhere."  The  knowledge  thus  far  gained 
relates  chiefly  to  three  different  points,  to  wit:  centres  of 
sensation,  centres  of  motion,  and  centres  of  language  _ 
But  it  is  chiefly  with  the  centres  of  motion  that  the  diag- 
nosis of  cerebral  injuries  is  mainly  concerned.  These 
portions  of  the  cerebral  substances  lie  around  the  fissure 
of  Rolando,  and  embrace  the  anterior  and  posterior  centra! 
convolutions.  This  portion  of  the  human  brain,  as  well  as 
the  corresponding  portion  of  the  brain  of  animals,  in  which 
like  phenomena  have  been  observed,  is  characterized  by 
the  presence  of  giant  pyramidal  cells,  which  are  only  found 
in  those  portions  of  the  cerebral  substance,  and  constitute 
a  structure  that  is  found  only  within  the  limits  of  the 
motor  area.  It  has  been  further  ascertained  that  the  power 
of  voluntary  motion  of  the  face  and  tongue  originate  in  the 
lower  third  of  this  region;  that  motions  of  the  arm  have 
their  origin  in  the  middle  third,  while  motions  of  the  lower 


extremity  originate  in  the  upper  third  of  this  motor  area. 
Injuries  of  other  portions  of  the  brain  may  often  be  inferred 
by  certain  nervous  phenomena;  but  the  localization  of 
most  other  functions  of  the  cerebral  hemispheres  has  not 
yet  been  ascertained  with  such  accuracy  as  to  make  it  a 
reliable  and  infallible  basis  of  diagnostic  opinion  or  of 
surgical  procedure. 

The  location  of  the  human  brain  is  such  as  to  make  it 
especially  liable  to  a  great  number  and  variety  of  traumatic 
injuries.  Forming  the  highest  portion  of  an  erect  body, 
exceedingly  liable  to  be  overturned,  it  usually  receives  from 
such  an  accident  the  severest  shock  that  is  borne  by  any 
portion  of  the  system.  It  is  the  objective  point  of  fists, 
bludgeons  and  missiles  in  all  personal  encounters;  and  it 
seems  to  be  the  recipient  of  an  undue  proportion  of  the  in- 
juries resulting  from  accidental  causes.  In  war  it  en- 
counters a  larger  proportion  of  destructive  missiles  than 
come  in  contact  with  any  other  portion  of  the  body  of  cor- 
responding size.  The  delicacy  of  the  structure  of  this 
organ,  and  the  want  of  firmness  or  tenacity  of  its  tissues 
renders  it  liable  to  destructive  lesions  from  a  degree  of 
violence  that  would  do  little  harm  to  other  portions  of  the 
system.  A  blow  from  the  fist  upon  any  portion  of  the 
cranium  leaving,  perhaps,  no  external  mark  of  violence,  may 
cause  a  fatal  lesion  of  some  portion  of  the  brain;  or  the  re- 
sulting concussion  may,  without  appreciable  lesion,  so 
shock  and  paralyze  the  nervous  centres  as  to  endanger,  or . 
perhaps  to  destroy  life.*  Or  a  haemorrhage  within  the 
cranium  may  be  produced  by  similar  apparently  slight 
causes,  and  by  its  pressure  involve  an  equally  dangerous 
result. 

But  it  is  the  more  violent  forms  of  injury  of  the  brain 
and  its  associated  organs  that  I  propose  at  present  to  con- 

*See  note  i. 


slder.  These  consist,  for  the  greater  part,  of  fractures  of 
the  skull  and  consequent  and  associated  injuries  of  the 
cerebral  mass  and  its  enveloping  membranes.  Fractures  of 
the  cranial  bones,  unless  associated  with  lesion  of  the  brain, 
do  not  come  within  the  purview  of  our  present  discussion. 
While  fractures  of  the  skull  may  and  often  do,  occur  with- 
out an  involvement  of  the  brain,  the  latter  organ  is  often 
injured  by  displaced  fragments  of  the  cranial  bones,  pressing 
upon  the  surrounding  membranes,  or  penetrating  its  sub- 
stance. Sharp  or  pointed  instruments  sometimes  penetrate 
it  more  or  less  deeply.  Missiles,  like  bullets,  fragments  of 
shells,  arrows,  fragments  of  iron  impelled  by  an  exploding 
boiler,  etc.,  produce  an  endless  variety  of  injuries  of  this 
organ.  These  may  penetrate  its  substance  to  any  depth, 
may  pass  entirely  through,  or  lodge  within  its  substance, 
and  may  carry  with  them  fragments  of  bone,  portions  of 
clothing  or  other  material,  to  be  deposited  along  the  line 
which  they  traverse  through  this  organ. 

When  the  recipient  of  one  of  these  injuries  survives 
long  enough  to  allow  a  surgeon  to  be  called  to  his  assis- 
tance, the  doctor  usually  feels  a  greater  degree  of  embar- 
rassment and  uncertainty  in  regard  to  the  measures  to  be 
adopted  for  the  promotion  of  his  patient's  recovery,  as  well 
as  to  the  probable  result  of  either  the  injury  or  its  treatment, 
than  he  is  accustomed  to  experience  in  the  management  of 
any  other  class  of  injuries.  His  patient  is  probably  uncon- 
scious, and  no  interrogation  of  him  can  elicit  any  informa- 
tion that  can  serve  to  guide  his  treatment.  A  slight  exter- 
nal wound  is,  perhaps,  the  only  visible  injury;  yet  it  is 
evident  that  beneath  the  cranium,  hidden  from  view,  inac- 
cessible to  the  touch,  and  secluded  from  all  his  powers  of 
observation,  there  exists  a  serious  lesion  of  the  brain.  In 
regard  to  its  precise  nature,  its  exact  location  or  extent  he 
feels  altogether  uncertain;  and  he  is  likely  to  feel  a  corres- 
ponding uncertainty  as  to  the  most  appropriate  and  efficient 


measures  to  be  adopted.  If  he  turns  to  the  standard 
authors  in  surgical  hterature  for  guidance,  he  finds  but 
scanty  aid — for  the  precepts  there  laid  down  for  his  guid- 
ance in  such  cases,  are  diverse  and  contradictory.  If  he 
relies  upon  his  own  experience  and  judgment,  he  is  likely 
to  find  that  what  he  has  seen  in  other  apparently  similar 
cases  is  by  no  means  repeated  in  the  present  one.  His 
greatest  embarrassment  comes  from  the  impossibility  of 
knowing,  with  precision  the  exact  nature  or  extent  of  the 
injury.  If  he  attempts  to  explore  the  wounded  organ  and 
to  ascertain  the  location  and  extent  of  the  injury,  he  is  not 
only  liable  but  likely  to  complicate  the  existing  injury.  If 
he  pursues  a  "'  Mastcjdy  inactivity"  h\^  patient  may  die  for 
the  want  of  some  simple  procedure,  like  the  removal  of  a 
spiculum  of  bone  or  other  material  that  has  been  carried  into 
the  substance  of  the  brain,  and  which  is  easily  accessible. 
What  then  can  he  do? — Or  what  should  he  do?  How 
shall  he  decide  the  uncertain  problem  and  execute  the 
serious  duty  that  confronts  him?  It  would  seem  that  the 
course  of  duty  must  lay  somewhere  between  officious  inter- 
ference on  the  one  hand  and  a  blind  and  passive  trust  in 
the  recuperative  powers  of  nature  on  the  other.  There  are 
undoubtedly  cases  in  which  the  most  radical  and  heroic 
procedures  are  not  only  justifiable  but  imperative.  There 
are  others  in  which  any  active  interference  can  only  do 
positive  harm,  and  greatly  diminish  any  existing  chances  of 
recovery.  A  wise  discretion,  therefore,  will  incline  him  to 
set  aside  all  rigid  rules  of  procedure;  to  discard  so  called 
"authorities,"  and  to  judge  for  himself  what  are  the  indica- 
tions for  treatment  in  the  particular  case  that  he  has  in  hand. 
He  should  consider  that  there  are  widely  differing  degrees 
of  susceptibihty  in  different  portions  of  the  brain — that  the 
anterior  and  middle  lobes  of  the  brain  are  more  tolerant  of 
traumatic  lesion  than   other  portions  of  the  organ,*   and 

*See  note  ii. 


that  while  they  are  more  liable  to  suffer  from  the  effects  of 
severe  concussion,  and  in  their  basilar  parts  are  especially 
liable  to  laceration  from  the  latter  cause — they  more  fre- 
quently recover  from  destructive  injuries,  like  penetration, 
laceration,  and  loss  of  substance,  than  do  any  other  portions 
of  the  cerebral  mass.  He  should  remember  too  that  all  les- 
ions of  the  brain  become  more  serious  as  they  approach  the 
central  and  basilar  portions,  and  that  the  difficulties  and  dan- 
gers of  surgical  interference  in  these  localities  are  corres- 
pondingly enhanced.  He  should  in  noca.se  act  with  undue 
haste.  The  case  may  at  first  seem  much  worse  than  it  real- 
ly is.  The  brain  may  be  so  shocked,  aside  from  any  actual 
lesions,  that  its  functions  are,  for  the  time,  almost  suspend- 
ed— just  as  a  bar  of  magnetic  iron  loses  its  magnetic  power 
by  receiving  a  violent  blow.  He  should,  therefore,  unless 
some  urgent  necessity  for  immediate  interference  exists  — 
such  as  a  dangerous  compression  or  irritation  from  a  depres- 
sed or  detached  fragment  of  skull  or  other  substance,  or  an 
exhausting  haemorrhage— give  sufficient  time  for  the  system 
to  rally,  so  far  as  it  may,  from  the  more  transient  effects  of 
the  injury,  before  proceeding  to  any  operative  measures. 

In  whatever  he  undertakes  to  do,  he  should  be  guided 
by  the  conditions  and  symptoms  presented.  There  may 
be  slight  external  marks  of  injury;  and  yet  there  may  be 
an  extensive  fracture  of  the  inner  table  of  the  skull,  pro- 
ducing compression,  laceration,  or  haemorrhage  of  the 
brain.  If  the  signs  of  these  conditions,  or  any  of  them, 
are  present  and  persistent,  an  exploration  of  the  injured 
part,  and  elevation  of  the  depressed  bone, — and  if  need  be, 
— the  removal  of  a  superficial  clot,  and  measures  for  the 
arrest  of  haemorrhage  should  be  undertaken.  This  may 
involve  the  use  of  the  trephine,*  and  it  should  be  boldly 
resorted  to  when  the  indications  for  its  use  are  apparent. 
This  class  of  cases  is  usually  very  perplexing  to  the  sur- 

*See  note  iii. 


10 

geon;  for  the  slight  external  injury  serves  as  but  a  doubt- 
ful guide  in  locating  the  serious  injury  which  he  is  seeking 
to  relieve.  The  localization  of  cerebral  functions,  as  ascer- 
tained by  recent  physiological  investigations,  will,  in  some 
instances,  enable  him  to  determine  the  seat  of  the  injury.* 
In  other  cases  there  may  be  a  more  or  less  extensive  ex- 
ternal wound,  with  manifest  depression;  and  yet  the  case 
may  present  no  symptoms  that  would  justify  the  measures 
necessary  for  an  elevation  of  the  bone.  These  cases  should 
be  sedulously  watched.  Symptoms  may  be  developed  that 
demand  an  application  of  the  trephine.  Whatever  symp- 
toms appear,  or  whatever  complications  arise,  should  be 
met  and  combatted,  as  they  become  apparent,  by  an  appli- 
cation of  the  general  principles  of  surgery — otherwise 
they  should  be  skillfully  let  alone.  In  still  other  cases,  an 
extensively  shattered  skull,  and  a  like  extensively  wounded 
brain,  may  be  presented.  The  patient  may  be  conscious  or 
comatose,  sensitive,  anaesthetic  or  paralytic,  according  to 
the  location  and  extent  of  the  injury.  A  prompt  removal 
of  depressed  and  displaced  fragments  of  bone  and  other 
foreign  or  vulnerating  materials,  when  they  can  be  readily 
found  will,  in  such  cases,  be  the  most  judicious  course.  If 
the  patient  survives  the  direct  effects  of  one  of  these  in- 
juries, there  are  various  complications  that  may  arise  in  its 
subsequent  history.  Inflammation  of  the  brain,  and  of  its 
membranes,  with  their  resulting  sequences,  are  to  be,  if 
possible,  averted;  or  met  and  combatted  by  prompt  and 
vigorous  measures  if  they  appear.  The  patient  should  in 
all  cases  be  kept  quiet,  and  if  possible  in  a  darkened  room. 
The  head  should  be  elevated  and  kept  cool.  The  cerebral 
circulation  should  be  moderated  by  bromides,  and  general 
antiphlogistic  measures  adopted.  If  symptoms  of  cerebral 
or  meningeal  inflammation  arise,  no  time  should  be  lost, 
and  no  reasonable  effort  spared,  in  combatting  them.     The 

*  See  note  iv. 


II 

head  should  be  shaved,  and  ice  applied  to  the  scalp.  Active 
purgation,  counter-irritants  to  the  extremities,  and  the  local 
abstraction  of  blood,  should  be  resorted  to;  even  the  "lost 
art"  of  bleeding  might  here  well  be  revived,  and  again  put 
into  requisition.  Should  bromides  prove  inefficient  in 
controlling  nervous  excitement,  opium  should  be  substi- 
tuted for  or  combined  with  it.  Every  measure  that  can 
tend  to  diminish  cephalic  irritation  should  be  promptly  and 
energetically  employed.  As  the  inflammatory  process, 
unless  limited  or  controlled,  must  certainly  be  fatal,  its 
appearance  should  always  be  met  by  early,  prompt  and 
energetic  treatment.  Should  the  patient  survive  the  acute 
inflammatory  stage,  there  still  remain  the  dangers  of 
diffused  suppuration;  of  abscess;  of  paralysis;  of  fungus 
cerebri;  with  the  more  remote  contingencies  of  cerebral 
softening  and  epilepsy.  If  paralysis  appears  early  in  the 
case,  it  usually  indicates  destruction  of  some  cerebral 
nerves,  or  of  that  portion  of  the  brain  in  which  they  origi- 
nate. Unless  it  is  due  to  pressure  from  a  depressed  portion 
of  bone,  it  is  in  that  case,  usually  permanent.  If  it  comes 
on  later,  it  is  probably  due  to  arrest  of  function, — as  from 
clot  or  abcess,  and  the  prospect  of  ultimate  improvement 
is  somewhat  better.  If  an  abcess  forms,  and  can  be  located 
with  sufficient  precision,  its  contents  should  be  evacuated. 
If  the  condition  known  as  "fungus  cerebri"  appear,  gentle 
compression,  astringents  locally  applied,  and  excision  of 
the  protruding  mass  are  to  be  resorted  to. 

As  the  formation  of  ascess  is  one  of  the  frequent 
sequences  of  cerebral  or  meningeal  inflammation,  especially 
that  resulting  from  traumatic  causes,  it  is  often  as  difficult 
as  it  is  important,  to  decide  upon  its  location  when  the  fact 
of  its  existence  has  been  determined.  If  it  is  known  to  be 
superficial; — if  it  lies  immediately  beneath  the  cranial  bones 
or  immediately  beneath  the  dura  mater  —  i  e,  if  it  has 
resulted  from  inflammation  of  the  cranial  bones,  or  of  the 


12 

dura  mater,  or  arachnoid,  its  evacuation  can  readily  be 
accomplished  by  an  application  of  the  trephine.  In  such 
cases  the  seat  of  the  original  injury  will  often  be  an  efificient 
guide  in  determining  the  location  of  the  abcess.  If  it  be 
located  in  the  superficial  substance  of  the  brain,  its  situa- 
tion may  often  be  determined,  and  its  evacuation  effected 
in  a  similar  manner.  Of  course  the  trocar  or  the  aspirat- 
ing needle  will  be  required  in  addition.*  It  may  be  im- 
portant to  determine  in  advance  of  an  operation  whether 
an  e.Kisting  abscess  is  d±ep  or  superficial, — in  other  words, 
whether  it  is  the  result  of  cerebral  or  meningeal  inflamma- 
tion. There  are  no  means  presented  by  the  syniptojiis 
resulting  from  these  conditions,  which  have  enabled  us  to 
distinguish  inflammation  of  the  brain  from  that  of  its  en- 
veloping membranes.  It  has  been  suggested  by  Dr.  Agnew 
— and  the  correctness  of  his  suggestion  has  been  frequently 
confirmed  by  observation — that  this  matter  might  be  deter- 
mined by  observing  the  comparative  force  in  the  temporal 
and  carotid  arteries.  The  temporal,  occipital,  frontal,  and 
meningeal  branches  of  the  internal  maxillary  arteries  have 
a  free  inosculation  in  the  diploe  of  the  cranial  bones, 
making  a  free  vascular  communication  between  the  arach- 
noid and  dura  mater  and  the  cranial  bones  and  scalp; 
while  the  brain  and  pia  mater  receive  their  blood  supply 
from  the  internal  carotid  and  vertebral  arteries.  It  follows, 
therefore,  that  in  meningeal  inflammation,  when  the  arach- 
noid, the  dura  mater  and  their  exterior  structures  are  alone 
inflamed,  the  temporal  arteries  will  be  observed  to  beat 
with  peculiar  force ;  when  the  pia  mater  and  the  brain  are 
alone  involved  in  the  inflammatory  process,  the  carotid 
arteries  display  a  similar  energy.  When  the  brain  and  all 
its  membranes  are  alike  implicated,  both  sets  of  vessels  are 
similarly  affected. 

The  rupture  of  a  vessel  within  the  cranial  walls  often 

*See  note  v. 


13 

gives  rise  to  a  dangerous  compression,  of  the  brain,  with 
resulting  paralysis  and  coma.  Its  extent  is  frequently  such 
that  its  location  cannot  be  decided  by  the  symptoms  which 
it  produces.  Like  other  injuries  of  the  brain,  the  resultin^^ 
effects  are  observed  on  the  opposite  side  of  the  body.  This, 
with  the  marks  of  injury  which  may  have  been  left  by  the 
blow  which  produced  it,  often  give  the  only  clew  to  its 
location.  As  the  only  relief  for  such  an  accident  consists 
in  the  removal  of  the  compressing  clot,  if  it  is  superficial, 
and  if  its  site  can  be  determined  with  reasonable  probabili- 
ty, the  trephine  should  be  applied  and  the  clot  removed. 
If  symptoms  of  compression  have  been  developed  imme- 
diately after  the  reception  of  the  injury,  it  is  to  be  supposed 
that  the  point  of  haemorrhage  is  where  the  middle  menin- 
geal artery  enters  the  cranial  cavity,  or  at  the  anterior 
inferior  angle  of  the  temporal  bone.  If  the  trephine  be 
applied  to  this  point,  the  compressing  clot  m  ly  sometimes 
be  found  and  removed  —  if  not,  the  meningeal  artery  may 
be  tied  and  further  haemorrhage  arrested.  When  failing  to 
find  the  offending  clot  at  this  point,  if  the  symptoms  are 
sufficiently  urgent,  a  similar  exploration  may  be  made 
along  the  course  of  the  inferior  meningeal  artery.  Extra- 
vasation in  the  cavity  of  the  arachnoid  has  occasionally 
been  relieved  by  a  similar  procedure.  When  it  lies  beneath 
the  pia  mater  or  in  the  deeper  tissues  of  the  brain,  I  am 
unacquainted  with  any  efficient  measures  for  its  relief 

Penetrating  and  perforating  wounds  of  the  brain  are 
usually  made  by  missiles  projected  by  firearms.  These  fre- 
quently carry  into  and  lodge  within  the  cerebral  substance 
some  foreign  materials,  like  felt,  hair,  fragments  of  the 
cranial  bones,  etc.  The  missiles  themselves  may  either 
lodge  within  the  cranial  cavity  or  make  their  exit  by  a 
second  perforation  of  the  skull.  A  very  large  proportion  of 
these  injuries  are  speedily  fatal.  A  less  number  survive 
for  a  limited  period;  and  a  still  smaller  proportion  either 
partially  or  completely  recover. 


H 

If  the  wound  be  a  perforating  one  it  will  usually  be 
found  that  the  missile  has  traversed  a  direct  course  through 
the  brain  between  the  points  of  its  entrance  and  its  exit  in 
the  cranial  walls.  It  will  ordinarily  be  easy  and  safe  to  ex- 
plore its  course  through  the  encephalon,  to  discover  and  to 
remove  any  foreign  or  injurious  materials  that  may  have 
lodged  along  its  course.  The  inner  table  of  the  skull  will 
always  be  found  more  extensively  fractured,  at  the  point  of 
entrance  than  the  outer  one;  and  more  or  less  completely 
detached  pieces  of  the  inner  table  will  usually  be  found  im- 
pinging upon  the  membranes,  perforating  their  walls  or 
penetrating  more  or  less  deeply  the  cerebral  tissues.  These 
should,  if  practicable,  be  removed;  and  if  the  small  size  of 
the  external  opening  interferes  with  the  necessary  proced- 
ures it  should  be  enlarged  by  the  trephine.*  It  seems 
needless  to  say  that  these  measures  should  be  conducted 
with  the  utmost  delicacy  and  care  and  that  the  greatest 
caution  should  be  observed  in  guarding  against  the  possi- 
bility of  inflicting  any  addit  onal  wound  or  injury  of  the 
brain  or  its   membranes. 

In  penetrating  wounds  of  the  brain,  when  the  mis- 
sile has  lodged  within  the  cranial  mass,  the  position  of 
the  attending  surgeon  is  often  a  difficult  and  embarrass- 
ing one.  The  patient  has  survived  the  immediate  effects 
of  the  injury,  but  a  bullet  or  other  projeciile  has  pene- 
trated the  brain  and  lodged  he  knows  not  where.  He  is 
uncertain  of  the  course  it  has  taken  —  of  how  deeply  it 
has  penetrated,  or  what  damage  it  has  inflicted  along  the 
track  which  it  has  traversed;  or  what  irritating  or  vulnerat- 
ing  materials  it  may  have  lodged  along  its  course.  He  can 
do  little  towards  rescuing  his  patient  from  his  perilous  con- 
dition until  he  has  gained  accurate  information  upon  these 
doubtful  points.  But  the  procedures  necessary  to  elicit 
this  information  may,  unless  carefully  executed,  be  fraught 

*See  note  vi. 


15 

with  peril,  both  to  his  patient  and  to  himself  If  he  makes 
no  attempt  to  discover  and  to  remove  the  missile,  and  death 
ensues,  he  is  likely  to  be  charged  with  negligence  and  want 
of  skill,  and  made  to  suffer  in  reputation  and  in  purse.  If 
he  explores  the  wounded  brain,  and  seeks  to  discover  and 
to  remove  the  ofifendinp"  materials,  his  best  conceived  efforts 
in  this  direction  may  totally  fail,  and  ensuing  death  be  at- 
tributed to  his  most  laudable  efforts  to  avert  it  The  old 
travesty  upon  the  doctrine  of  predestination — 

"  You'll  be  damned  if  you  do, 
You'll  be  damned  if  you  don't," 

seems  especially  applicable  to  him;  and  if  still  more  unfor- 
tunately the  case  which  he  has  in  hand  should  be  one  of 
attempted  or  accomplished  homicide,  he  is  liable  to  be 
assailed,  and  traduced  as  the  party  upon  whom  the  guilt 
and  penalty  involved  in  the  case  should  mainly  rest,  and  he 
should  make  it  certain  that  nothing  in  his  procedures  can 
verify  such  an  accusation. 

What  course  then,  should  a  surgeon  take  when  as- 
suming the  duties  and  the  responsibilities  pertaining  to  a 
case  of  penetrating  wound  of  the  brain? 

In  assuming  charge  of  such  a  case,  or  of  any  other, 
the  surgeon  should  ignore  all  considerations  relating  to 
himself,  to  his  pecuniary  interests  or  his  reputation.  His 
duty  to  his  patient  should  be  the  sole  consideration  that 
determines  his  course.  He  has  no  right  to  adopt  any 
measure,  or  to  perform  any  operation,  inspired  by  a  desire 
for  the  eclat  that  its  success  may  bring  him ;  still  less  has 
he  a  right  to  abstain  from  any  measure  that  in  his  judgment 
is  necessary  for  the  promotion  of  his  patient's  recovery,  or 
that  is  best  calculated  to  promote  it,  from  any  apprehension 
of  censure  that  would  attend  its  possible  failure. 

He  should  carefully  observe  the  general  condition  of 
his  patient,  the    location  and  appearance    of  the  external 


i6 

wound;  obtain  any  information  he  can  in  regard  ta  the 
nature,  size  and  propelling  force  of  the  missile,  and  of  the 
direction  from  which  it  came.  This  information  may  aid 
him  greatly  in  determining  his  subsequent  steps.  If  the 
missile  has  passed  beyond  the  surface;  if  it  is  of  large  size 
and  of  such  a  nature  that  it  must  necessarily  be  a  source  of 
irritation  and  danger,  a  careful  exploration  of  its  track 
should  be  made.  Far  this  purpose  the  finger  is  the  best 
instrument.  If  the  missile  or  other  foreign  materials  be 
found,  their  prompt  removal  should  be  effected.*  If  it  has 
penetrated  too  deeply  to  be  discovered  in  this  manner,  a 
blunt  or  bulbous  probe,  like  that  of  Nelaton,  may  be  passed 
carefully  along  the  track  made  by  the  missile  for  the  pur- 
pose of  discovering  its  location.  This  should  be  done  in 
the  most  careful  manner  possible ; — for  it  is  to  be  remem- 
bered that  the  texture  of  the  brain  is  so  destitute  of  con- 
nective tissue  that  an  exceedingly  slight  degree  of  force 
may  penetrate  it  in  any  direction.  An  ordinary  probe 
should  not  be  used  for  this  purpose,  or  if  used  at  all,  abso- 
lutely no  force  should  be  applied  to  it  after  entering  the 
brain.  If  its  own  weight  will  carry  it  along  the  course  of 
the  wound,  it  may,  perhaps,  be  used  in  that  manner  with 
reasonable  safety.  It  is  likely  to  do  no  harm,  and  to  give 
as  little  information.  But  a  slight  degree  of  force  applied 
to  its  propulsion  constitutes  a  new  element  of  danger;  for 
as  Dr.  Agnew  says,  no  one  can  tell,  when  applying  any 
force  to  an  ordinary  probe,  under  such  circumstances, 
whether  he  is  following  the  track  of  a  missile,  or  whether 
he  is  burrowing  a  new  channel  through  the  brain.  All 
recognized  authorities  condemn  such  a  method  of  probing 
the  brain,  and  an  additional  wound  made  by  such  a  proce- 
dure may  be  more  dangerous  than  the  original  injury,  and 
constitutes  not  only  a  surgical  blunder,  but  a  surgical 
crime. t     Unless  the  missile, — especially  if  it  be  a  leaden 

*See  note  vii.  fSee  note  xi. 


'7 

ball, — can  be  readily  found  and  easily  extracted,  it  is  usually 
safer  to  allow  it  to  remain  within  the  cranial  cavity  than  to- 
undertake  its  discovery  and  extraction  by  promiscuous 
probing  and  violent  measures  for  its  removal*.  Explora- 
tion of  the  brain,  if  resorted  to  at  all,  should  be  done  early. 
In  consequence  of  the  almost  entire  absence  of  contractile 
tissue  in  the  brain,  a  bullet  or  other  missile  in  penetrating 
it,  leaves  an  open  track  along  its  course.  If  a  small  probe 
be  introduced  into  such  a  wound,  its  own  weight,  if  the 
position  be  favorable,  will  be  sufficient  to  carry  it  forward 
as  long  as  the  wound  remains  unobstructed  by  clots.  But 
wlien  these  form  and  have  acquired  firmness,  they  will 
offer  about  the  same  resistance  as  the  normal  brain  struc- 
ture, and  then  it  must  become  difficult  or  impossible  for 
the  surgeon  to  know  whether  he  is  pushing  his  instrument 
along  the  course  of  a  wound  previously  existing,  or 
whether  he  is  inflicting  another  and  an  equally  dangerous 
one. 

Does  the  probability  of  benefit  to  the  patient,  arising 
from  an  exploration  of  the  brain,  and  a  search  for  a  missile 
which  has  lodged  in  its  deeper  structures,  justify  such  a 
proceeding?  If  dangerous  symptoms  arise,  and  if  the 
foreign  body  can  be  discovered  in  any  portion  of  the  brain, 
and  its  extraction  accomplished  by  such  measures  as  do 
not  add  to  the  original  peril,  their  removal  should  usually 
be  undertaken.  But  if  they  cannot  be  found  without  a 
promiscuous  and  guideless  hunt  through  the  brain,  they 
had  better  be  let  alone.  This  organ  occasionally  shows  a 
remarkable  tolerance  of  foreign  bodies,  especially  metallic 
substances,  like  lead  and  iron,  which  readily  become 
encysted,  and  have  remained  for  long  periods  of  time  com- 
paratively harmless  tenants  of  the  brain,  or  giving  but 
slight  evidence  of  disturbance  from  their  presencef.  I 
would,  therefore,  in  a  doubtful  case,  prefer  to  give  a  patient 

*  See  note  viii.  fSee  note  ix. 


the  benefit  of  the  chances  which  this  fact  affords,  rather 
than  to  subject  him  to  the  dangers  which  attend  the  inflic- 
tion of  an  additional  injury,  with  the  remote  and  uncertain 
prospect  of  resulting  benefit. 

If  the  missile  inflicting  the  wound  be  of  small  size  and 
the  external  wound  correspondingly  small,  and  no  danger- 
ous symptoms  are  presented — unless  the  missile  is  located 
quite  superficially — no  attempt  should  be  made  to  explore 
its  course  through  the  brain,  or  to  attempt  its  removal. 
Such  measures  would  probably  be  attended  with  more 
serious  consequences  than  the  original  injury.  I  have  seen 
patients  recover  from  such  a  wound  in  the  anterior  and 
middle  portions  of  the  brain  without  ever  exhibiting  any 
symptoms  that  w^ould  indicate  a  serious  injury. 

Or  if,  on  the  other  hand,  the  missile  has  evidently 
penetrated  the  deep  and  central  portions  of  the  brain  and 
lodged  among  the  ganglia  at  its  base,  there  is  little  to  be 
hoped  for  from  any  attempt  to  discover  its  exact  location 
and  to  effect  its  removal.  It  is  likely  to  be  fatal  sooner  or 
later  if  it  remains;  but  the  probability  of  prolonging  life 
by  attempting  its  removal  is  so  slight  as  scarcely  to  justify 
an  effort  in  that  direction. 

If  it  has  penetrated  the  upper  or  frontal  portion  of  the 
brain,  if  the  missile  is  of  large  size  and  is  of  a  nature  that 
must  necessarily  render  it  a  permanent  source  of  irritation; 
or  if  it  has  passed  through,  or  nearly  through  the  brain, 
and  lodged  at  or  near  the  surface,  its  removal  should  be 
attempted.  In  the  latter  case,  a  counter-opening  through 
the  skull  will  facilitate  its  extraction.  Here,  as  in  every 
wound  of  the  brain,  thorough  drainage  and  the  most  scrup- 
ulous aseptic  dressings  should  be  rigidly  adhered  to 
through  the  entire  course  of  treatment. 

Experience  has  shown  that  there  are  few  portions  of 
the  brain  into  which  missiles   have  not  found  their  way* 

*See  note  x. 


19 

and  lodged  for  considerable  periods  of  time,  without  giving 
rise  to  any  serious  disturbance  of  the  system.  These,  it  is 
true,  are  exceptional  cases — but  we  know  that  they  may 
occur;  and  they  do  occur  with  such  frequency  that  in 
doubtful  cases  it  would  seem  more  prudent  to  accept  the 
slender  chances  that  their  possibility  bestows,  rather  than 
to  complicate,  by  surgical  procedures,  even  a  prospectively 
fatal  injury  with  a  view  to  the  doubtful  benefits  that  may 
arise  from  their  performance. 

Whether  the  wounding  missile  be  removed  from  the 
brain  or  left  within  it,  the  subsequent  treatment  should  be 
conducted  upon  the  general  principles  already  stated. 


NOTES. 


Note  i. — Otis.  Med.  and  Surg.  Hist.  War  of  Rebellion,  pt.  i, 
surg.  b.,  pg.  65.  Thirteen  cases  of  deaths  reported  from  concussion 
of  brain. 

Note  ii. — Ifi/d,  pg  68.  Fractures  of /ron fa/  bones,  resulted  .  .  . 
22  cases:  10  died,  6  discharged,  5  returned  to  duty.  Parietal,  33 
cases:  15  died,  12  discharged,  4  returned  to  duty,  2  unknown. 
Temporal,  7  cases:  6  died,  i  discharged.  Occipital.  All  died. 
Base  of  skitll,  1 1  cases.     All  died. 

Note  hi.— J.  A  Liddell.  Am.  J.  Med.  Sciences,  April,  1882. 
Sixty-three  cases  of  fracture  of  inner  table  of  skull  without  external 
fracture:  .Seven  cases  recovered,  six  of  -these  were  trephined  — in 
one  necrosis  of  external  table  occurred — 56  ended  fatally 

Noi'E  IV.  —  Stromcyer  claims  to  be  able  to  correctly  diagnose 
and  to  locate  fractures  of  inner  table  of  skull  by  percussing  with  a 
silver  probe  over  the  suspected  section. 

Notk  v.  —  Fenger.  Am.  J.  Med.  Sci.,  July,  1884.  Aspirated 
abscess  in  frontal  lobe  2^  inches  from  surface — entered  needle  in 
several  directions  before  finding  abscess — recovery. 

NdTI',  V!.  — Med  &  S.  II.  W.  R  ,  p't.  i,  pg.  276.  Operation  by 
Dr.  Bliss -recovery. 

Notk  v;l  —  ibid  —  V'g.  196,  et    seq. 

N;r!'|..  V!i:.  — ,'^w/  ]?6  wounds  of  cranial  cavitv  loi  fatal— 85 
casc-T  of  removal  of  missile  witli  .13  iccoverics.  101  cases  in  which 
projcctik"  was  not  removed,  59  fatal  and  42  more  or  less  completely 
rc'.ovcred. 

Noil'.  1  ;  -  Dr.  II,  D.  Noyes.  (Am.  J.  Med.  Sciences,  July, 
1884,)  removed  breecli  pin  of  gun  .\  "/-if^  Inches  long,  }4  inch  wide, 
fiorn  nose  ocIhl  aii'i  b  ain,  in  wiiii  h  it  had  remained  five  months 
without  producing  serious  disturbance.  //'iJ,  pg.  59.  Dr.  Daniel 
liurr  reported  case  in  which  tube  and  nipple  of  gun  were  carried  in 


21 

brain  four  months  without  disturbance  of  health.  Ibid,  Jan.  1885, 
pg.  128.  Dr.  G  W.  H.  Kemper  relates  case  of  breech  pin  of  gun 
\%,  inches  long  removed  from  brain— recovery. 

Note  X. — Gross  System  of  Surgery,  vol.  ii,  pg.  160  et.  seq. 

No'l'E  XI. — "There  can  be  no  doubt  that  all  extraneous  sub- 
stances within  view  or  reach,  in  cases  of  penetrating  wounds  of  the 
cranium,  should  be  removed  by  the  surgeon;  but  before  he  com- 
mences any  unguided  search  for  them  in  the  fragile  structure  of  the 
brain,  he  ought  seriously  to  consider  the  injury  which  he  may  inflict. 
He  should  remember  that  patients  have  died  under  the  surgeon's 
hands  while  exploring  the  brain  to  find  foreign  bodies;  and  further- 
more, that  life  has  been  preserved  in  many  instances  where  they 
have  not  been  looked  after,  or  their  presence  unsuspected.  When 
the  track  of  a  leaden  ball,  or  any  other  body  is  to  be  traced  through 
the  brain,  an  elastic  bougie  may  well  be  employed  for  the  purpose. 
In  its  absence  a  female  catheter,  or  the  porcelain-tipped  probe  of 
Nelaton  may  be  employed.  These  instruments  should  be  allowed  to 
sink  into  the  wound  by  their  own  weight;  they  should  not  be  pushed 
forcibly  ojiiuard.  It  is  better  to  temporize  than  to  probe,  violently, 
an  injured  brain.  Great  care  should  be  taken  that  the  exploring 
instrument  is  not  thrust  out  of  the  track  of  the  foreign  body.  When 
the  site  of  the  missile  cannot  be  found  by  one,  or  at  most  two  explo- 
rations of  the  wound,  further  attempts  to  find  it  by  probing  should 
not  be  allowed." — Holmes'  System  of  Surs;ery,  vol.  i,  p.  657. 

"The  finger  is,  of  course,  the  best  probe,  but  all  officious  inter- 
ference is  to  be  avoided,  inasmuch  as  it  is  far  better  to  let  the  missile 
and  even  detached  pieces  of  bone  remain  where  they  are,  than  to 
search  for  them  at  the  risk  of  severe  additional  injury." — Gross' 
System  of  Surgery,  vol.  ii,  p.  161. 

"In  cases  of  penetration,  any  exploration  in  search  of  the  missile 
should  be  conducted  with  the  utmost  caution.  It  is  impossible,  after 
a  probe  has  passed  out  of  sight,  to  know  whether  it  is  following  the 
track  made  by  the  ball,  or  whether  it  is  penetrating  the  brain  sub- 
stance; and  therefore,  when  the  opening  in  the  skull  is  sufficient  to 
admit  the  finger,  the  latter  should  be  used  in  preference  to  any  other 
means  of  exploration.  If  fragments  of  bone,  or  any  other  foreign 
matter  can  be  detached  without  needlessly  pressing  the  examination, 
they  should,  by  all  means,  be  extracted;  but  unless  they  are  quite 
accessible  and  easily  located,  all  such  attempts  can  only  be  produc- 
tive of  evil,  and  should  be  discouraged, " — Agnew's  Surgery,  vol.  i, 
p.  293. 


1010236562 


RD529 
Crawford 


C85 


